Cardiac Rehabilitation and Return to Unsupervised Exercise

Cardiac Rehabilitation is a medically based, professionally supervised program that assists people in recovering from heart attacks, heart surgeries, and other coronary interventions such as PTCA (angioplasty) and stenting.

Cardiac rehab intervention, most often prescribed by doctor referral, has been shown to reduce rates of re-hospitalization, lower mortality rate, decrease the need for cardiac medications, and increase the rate at which people return to work.

In cardiac rehabilitation, clients are carefully monitored and under the supervision of a cardiac registered nurse and other medical professionals. There is a crash cart present in the facility for if an emergency arises. Clients are taught to self monitor and connect with their body through Rate of Perceived Exertion (RPE) and other means in order to listen to their body, monitor symptoms, and to exercise safely and appropriately.

Special medical training and equipment is required in cardiac rehabilitation. Although clients may want to skip a long drive to go into town to go to cardiac rehab, or it may not be at convenient times, it is important that cardiac rehab be completed and they are cleared to join/participate in a community setting. It is very unwise to allow clients to participate in community programs without proper participation and clearance from cardiac rehabilitation. Physician’s consent for participation in a group fitness class, personal training, or small group training is strongly advised and initial (preferably ongoing) communication with the cardiac rehab team is encouraged.

Phases of Cardiac Rehabilitation
Phase Description
Phase I (Inpatient)
  • Provide patient education concerning lifestyle changes (heart healthy food choices, regular exercise and risk factor modification)
  • Provide education on intervention or surgery when hospitalized (signs/symptoms or heart attack, CHF, stent placement, CABG, PAD, etc.)
  • Ambulate patient if possible and provide information on home exercise program.
  • If patient has had open heart surgery, ROM exercises and/or ambulation daily, incentive spirometry, coughing/splinting and home activity guidelines especially for post discharge care.
Phase II (Outpatient)
  • Post-intervention patients
  • Physician referral needed
  • All patients monitored by telemetry units during individualized exercise program.
  • Patients taught how to monitor heart rate, RPE (rate of perceived exertion) and symptoms during exercise
  • Exercise sessions include ~30+ minutes of cardiovascular activity, moderate strength training (approval needed), and cardiovascular risk factor modification education on at least 3 days/week
  • Number of exercise sessions depends on condition and physical response to exercise
Phase III
(Wellness/Maintenance)
  • Non-monitored, supervised maintenance program
  • Can be located in hospital or other fitness facility
  • Exercise guidelines provided by progress in Phase II, physician recommendations, and patient’s needs/goals
Phase IV
(Wellness/Maintenance)
  • Home exercise guidelines given
  • May exercise at community facility
  • Encouraged to monitor Intensity (HR, RPE, symptoms, etc.)
  • Focus on making positive lifestyle changes
  • Some programs are Phase III/IV combined

Working with clients that have heart disease in a group or individual setting requires fitness professionals to follow safe guidelines and recommendations. It is important to understand these exercise guidelines especially for those who have heart disease and have attended cardiac rehabilitation phase 2. Educate yourself, seek advice, and consider shadowing an experienced professional when creating a client base for those who have been cleared to exercise in cardiac rehabilitation phase 3 and 4 programs.

The information in this course is from the FLS continuing education course “Healthy Heart for a Healthy Life” by Tina Schmidt-McNulty.
For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

The Development of Atherosclerosis Leading to Heart Disease

Inflammation and irritation of the coronary (heart) artery inner lining can be caused by years of smoking and uncontrolled hypertension and diabetes. These inflamed areas can start to collect cholesterol from the blood stream and begin to form plaque. This plaque begins to grow and decreases the diameter of the artery which compromises blood flow. This decrease can then potentially cause angina (chest pain) symptoms.

In certain situations, this plaque in the artery may rupture or break open which can lead to a formation of a clot in the coronary artery. The clot can block part of the artery preventing the oxygen-rich blood from being delivered to the heart muscle. Part of the heart can then die.

This is known as a heart attack or myocardial infarction. If action is not taken immediately and the condition treated, the part of the heart muscle not receiving oxygen may not be revived and is replaced with scar tissue. Over time, this scar tissue may hinder the ability of the heart to pump effectively and can lead to ischemic (lack of oxygen) cardiomyopathy. It can also lead to electrical conduction irregularities causing abnormal heart rhythms such as ventricular tachycardia or ventricular fibrillation which are associated with sudden cardiac death.

The 4 Steps of Atherosclerosis Development

Step 1:
Injury to inner cell lining

Inside of the artery consists of a single layer of cells called the endothelium, which protects the other layers from interacting with blood. Agents such as smoking, hypertension, elevated LDL levels and stress can potentially cause injury to the endothelium causing atherosclerotic

Step 2:
Relocation of inflammatory cells

When atherosclerotic lesions develop, the endothelial cells (inner layer of cells) cells start to bind to monocytes and other inflammatory cells that start atherosclerotic lesions. Once in these lesions, the monocytes start to travel between the inner lining of the artery and localize in the next layer (intima) where they transform into macrophages and start to engulf mainly LDL.

Step 3:
Accumulation and Smooth Muscle Cell Production

Smooth muscle cells move into the intima and divide. The macrophages that digest the lipids ultimately transform into foam cells that is protective in that it removes excess lipids from circulation. However, this accumulation eventually leads to the progress of the lesion. Active macrophages tarnish (oxidize) LDL and digest them to become foam cells. Macrophages and smooth muscle cells release collagen and other proteins.

Step 4:
Plaque structure

The plaque is now mature and is a collection of foam cells, proteins, smooth muscle cells, and cholesterol debris. This plaque can then harden, crack, cause blood clots to form, and even occlude (block) the vessel.

The information for this course is taken from the FLS continuing education course “Healthy Heart for a Healthy Life” by Tina Schmidt-McNulty.
For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

 

7 Essential Guidelines for Exercise for Diabetics

There are several precautions a client can take to not only prevent hypoglycemia, but to also have a safe exercise experience. Use these Guidelines to help your client avoid complications during exercise.

  1. Inject insulin in a part of the body that will not actively be used for exercise. The abdomen is recommended.
  2. Check blood glucose levels before, during and after exercise the first couple of exercise sessions and/or if trying a new activity.
    1. Activity type, intensity, and duration may affect glucose levels.
    2. Typically, 1 hour of exercise = additional 15 g of carbohydrates either before or after exercise.
  3. During exercise, a quick source of carbohydrates (that does not also contain fat) should be readily available such as orange juice or candy.
  4. Be aware of a delayed post-exercise hypoglycemia in those who take insulin.
    1. Metabolism may remain elevate for several hours post-exercise especially during the night.
    2. Check glucose at bedtime and again couple hours after (~1-2AM) especially on a day of increased activity.
  5. Adequate fluids before during and after exercise are recommended.
  6. Wear proper shoes with polyester or blend socks as well as inspecting feet after exercise to practice good foot care.
  7. Carry medical identification.

For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

6 Important Things to Know when Working with Cancer Patients and Survivors

Cancer is the second leading cause of death in the United States. Today, survival trends are improving, however the number of deaths caused by cancer has increased. More than one-third of yearly cancer deaths are related to diet and physical activity habits. Ironically, the same behaviors that contribute to decreasing the risk of cardiovascular disease such as being physically active, maintaining a healthy weight, and consuming a healthy diet can also significantly reduce the risk of developing cancer.

Exercise provides a significant role in prevention and control of cancer. The U.S. Department of Health and Human Services recommends that those with cancer should be as active as possible considering their current health and capacity, but to avoid inactivity. As with any chronic disease, approval from a physician is recommended before any exercise program prior to, during, or after treatment. Recent data supports that exercise may increase survival rates for both breast and colon cancer survivors, and there is evidence that the risk of cancer reoccurrence may be decreased when physically active during and after treatment. Exercise also plays a significant role in recovery and long-term health.

Overall, exercise comes highly recommended before, during, and after treatment to benefit the cardiovascular system and assist with muscle and bone strength; all of which can be challenged with treatments.

The most frequent cancer site is the skin. If you see moles or abnormal skin spots on your client, encourage them to see their physician immediately. Skin cancer can be deadly.

Here are 6 things to know when working with cancer patients and survivors:

  1. Exercise is not recommended if the client is on intravenous chemotherapy days or within 24 hours of treatment.
  2. No exercise prior to a blood draw.
  3. No exercise if the client has a tissue reaction to radiation therapy.
  4. No exercise if there is any bone, back, or neck pain of recent origin or any unusual muscular weakness.
  5. No exercise if fever greater than 101°F or nausea, vomiting, or diarrhea within 24-36 hours.
  6. Avoid high intensity resistance training for muscles located under or near a port or a PICC line. (A port is an implanted venous access port or totally implanted port used to insert treatments like chemotherapy into the blood stream and a PICC line is a permanently inserted flexible tube for long term intravenous medicine or treatments.) A PICC line is inserted in the upper arm or the fold in the elbow.  The port is normally implanted under the skin in the upper chest (pectoralis area), but can be inserted in the back of the upper arm (triceps area) or in the abdominal area.

The information for this article is taken from the continuing education course “Essential Exercises for Cancer Patients and Survivors” by Tina Schmidt-McNulty.
For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

6 General Recommendations for Working with Clients with Respiratory Conditions

Knowledge of the respiratory system and pulmonary function is fundamental for training the client with chronic conditions known as pulmonary disorders. These disorders are characterized by airflow obstruction, cardiovascular and muscular impairments, abnormalities of gas exchange, and psychological issues including fear and embarrassment that often accompanies shortness of breath. Properly done exercise can improve musculoskeletal and psychosocial factors that limit clients with pulmonary disease.

  1. It is important to do a longer warm up and cool down for clients with asthma, COPD, and other respiratory issues.
  2. Choose an appropriate, lower demand cardiorespiratory activity for beginner or compromised clients such as cycling or walking.  Switch to a lower demand exercise during periods of respiratory condition flare ups.
  3. Teach the client proper breathing techniques. There are breathing exercises such as “Pursed Lip Breathing” or “Diaphragmatic Breathing” that help with shortness of breath and the anxiety, fear, and embarrassment that may be present.
  4. Do not use continuous overhead arm work. This can cause the client fatigue by making the heart work harder.
  5. Incorporate resistance training, especially in the upper body to help improve stamina and function in the chest, upper back, shoulders, and arms.
  6. Do exercises in a well-ventilated area. Make sure room temperatures are not too low or too high for comfort.  Be aware of humidity and the presence of allergens or respiratory irritants that may be present in the exercise area.  Just opening windows during allergy season can cause an allergy or asthma attack.

The information in this article is from the FLS continuing education course “Respiratory Rescue” by Soraya Cates Parr.
For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

3 Things to Know When Working with Diabetic Clients

  1. Symptoms of Hypoglycemia
    Prevention of hypoglycemia is important for a safe exercise program for someone who has diabetes. Anyone taking insulin or an oral medication that may cause hypoglycemia should be aware of symptoms and how to manage this situation especially during exercise. Hypoglycemia occurs when glucose levels are < 70mg/dl.  This condition may become worse if not treated. Prevention is the best intervention.

 

Symptoms may include:

  • sweating
  • shaking
  • dizziness
  • headache
  • confusion
  • irritability
  • hunger
  • personality change
  • weakness
  • vision changes
  • seizures and/or loss of consciousness.
  1. Exercise Blood Sugar Guidelines
    Blood glucose should be checked and treated if the reading is below 70 mg/dl.
    Treatment: It is recommended to follow the “Rule of 15”:
    a. Eat 15 grams of carbohydrate, wait 15 minutes, then eat another 15 grams of carbohydrates if there is no improvement in symptoms. (Lobb-Oyos 2012)
    When exercising, blood glucose levels should be at least 100-110 mg/dl.
    b. If not, a carbohydrate should be consumed and levels can be rechecked before starting to exercise.
    c. Type 1 diabetics using insulin pumps may need to adjust insulin delivery during exercise and basal delivery rates for up to 12 hours post-exercise to avoid hypoglycemia. (ACSM 2017)

 

  1. Recommended Pre-Exercise Carbohydrate Intake
Pre-Exercise
Glucose
Exercise Intensity and
Duration
Additional Food
Needed
<100 mg/dl Low (< 30 min)
Moderate (30-60 min)
Strenuous (> 60 min)
15 grams of carbohydrate
30 grams of carbohydrate
60 grams of carbohydrate
101-170 mg/dl Low (< 30 min)
Moderate (30-60 min)
Strenuous (> 60 min)
No additional food necessary
15 grams of carbohydrate
30 grams of carbohydrate
171-300 mg/dl Low (< 30 min)
Moderate (30-60 min)
Strenuous (> 60 min)
No additional food necessary
No additional food necessary
15 grams of carbohydrate
>300 mg/dl *Blood sugar needs to be under control prior to starting exercise!

*(Type 1 DM Glucose > 250 mg/dl: Check for ketones; if present, notify physician)
(“Diabetes Medications: Guidelines for exercise safety” 2012)

The information in this article is from the continuing education course
“Exercise, Diabetes, and Metabolic Syndrome” by FLS author Tina Schmidt-McNulty.
For more information about working with clients with chronic disease, see the Fitness Learning Systems Chronic Disease and Exercise Specialist Certificate Program.  Specialize and become recognized as a medical fitness professional.  Fitness Learning Systems is an IACET accredited continuing education provider.

Hard-to-Recognize Heart Attack Symptoms

June Chewning, BS MA

In my 38 year career and 18 years owning a fitness center, I know heart attacks happen.  I have heard about them when members went home, sat up in bed, and dropped dead next to their spouse after a visit to the gym. I have made the ambulance ride to the hospital with them when they thought they just pulled a chest muscle, but their pulse and blood pressure were erratic. When they went back to work after a lunch time work out to look up the symptoms of heat attack on Google and realize it was happening to them right then. When they couldn’t figure out why their calves hurt so bad when they exercised, and when told to stop exercise and consult their physician had triple by-pass surgery the next day.  When my friend’s sister had a massive heart attack at age 40 because they thought she had a bruise instead of a blood clot in her leg.  When a young teacher thought she had the flu from her kids at school and went home early from aerobic class feeling nauseous and dropped dead at the threshold of her apartment.

Health-Fitness professionals, heart disease is the leading cause of death  in the US.  You will encounter it.  Be prepared and get educated. Be aware and vigilant about seeing the tell tale and not so obvious symptoms in your clients.  Save a life…

Healthy Heart, Healthy Life
eLearning Continuing Education Course for
Health-Fitness Professionals

This article is from
the American Heart Association
Go Red for Women Program

Well-known heart attack symptoms can include chest pain and radiating discomfort in the left arm. But, as Dr. Suzanne Steinbaum explains, there are several other ways your body may tell you when something isn’t quite right, potentially with your heart.
Read on for details on four silent heart attack symptoms that women should most definitely be aware of.

Shortness of breath
According to Steinbaum, director of The Heart and Vascular Institute at Lenox Hill Hospital in New York City, women often struggle to breathe a few weeks before experiencing a heart attack.
“If you are used to doing a certain amount of activity and then, all of a sudden, you can’t get enough air, that is when I get concerned,” says Steinbaum.

Back pain
Irregular pain in the lower or upper back can indicate stress to the heart muscle, Steinbaum says.

Jaw pain
“I had one patient who would feel her jaw start to hurt every time she got on a treadmill,” Steinbaum says. “But once she stopped, her jaw pain would go away. She went to a dentist, but there wasn’t anything wrong with her teeth.”
This discomfort continued until the woman experienced a heart attack. When she came into Steinbaum’s office after the event, it was evident that the jaw pain was directly linked to what was happening in her heart.
“Sometimes the heart isn’t able to give a good signal and, instead, the pain can radiate to the neck, jaw and back,” she says.

Nausea
Flu-like symptoms are often reported weeks and days before a heart attack. In fact, as Steinbaum explains, TV personality Rosie O’Donnell reportedly regurgitated a few times before she experienced a heart attack in early 2012.

Advice: Trust Your Gut
If you aren’t feeling normal or are experiencing any of the symptoms above, head to you local emergency room. It is better to take care of yourself and prevent damage to your heart, in the event you are having a heart attack.
“A women’s intuition is a very strong thing; don’t ever discount it,” Steinbaum says.
“Ninety percent of my women patients who’ve just had a heart attack tell me that they knew it was their heart all along. That they just had a feeling.”

Chronic Disease and Exercise

Chronic Disease: Unavoidable
By: June Chewning MA, BS

My brother once told me that “if you are born, you have a 100% chance of dying.” The other inevitable fact is that you have to die of something. Although neither of these statements is pleasant to contemplate, the reality is that at one point or another in most people’s lives, chronic disease is unavoidable. Chronic disease infiltrates the aging process, creates quality of life issues, and can in some cases be life altering.

Clients with chronic disease are also unavoidable. They are prevalent in the population in large numbers, and need health-fitness professionals to help them prevent, manage, and live a better life with the disease. With almost every chronic disease, research clearly indicates that exercise plays a role in prevention, recovery, and management of the disease.
One of the best ways to prepare yourself to work with clients with chronic disease is to educate yourself about the etiology, progression, and prevention of the disease so that you can safely and effectively use exercise as a tool to improve function and quality of life. With the need for medical fitness becoming more respected and sought after, proper knowledge becomes essential to safe and effective intervention.

Here are 4 Chronic Disease tips to help you move toward better practice with chronic disease clients.
1. Proper health history and risk factor analysis is critical to the foundation of working with clients with chronic disease. Use it to discover presence of disease and possibly multiple diseases, risk of disease to apply prevention strategies, history of disease progression, and current function and activity levels to establish a starting point. In chapter 10 of the ACSM Guidelines for Exercise Testing and Prescription 9th edition, there is a great section with information and guidelines for working with Individuals with Multiple Chronic Diseases and Health Conditions.

2. Prevention of hypoglycemia (low blood sugar) is important for a safe exercise program for someone who has diabetes. If you work with someone taking insulin or an oral medication that may cause hypoglycemia, you should be aware of symptoms and how to manage this situation especially during exercise. Hypoglycemia occurs when glucose levels are < 70mg/dl. This condition may become worse if not treated. Prevention is the best intervention.
Symptoms may include:
• sweating
• shaking
• dizziness
• headache
• confusion
• irritability
• hunger
• personality change
• weakness
• vision changes
• seizures and/or loss of consciousness.

3. When working with cancer patients and survivors, avoid high intensity resistance training for muscles located under or near a port or a PICC line. (A port is an implanted venous access port or totally implanted port used to insert treatments like chemotherapy into the blood stream and a PICC line is a permanently inserted flexible tube for long term intravenous medicine or treatments.) A PICC line is inserted in the upper arm or the fold in the elbow. The port is normally implanted under the skin in the upper chest (pectoralis area), but can be inserted in the back of the upper arm (triceps area) or in the abdominal area.

4. When working with clients with Respiratory disease, it is important to do a longer warm up and cool down for clients with asthma, COPD, and other respiratory issues. Choose an appropriate, lower demand cardiorespiratory activity for beginner or compromised clients such as cycling or walking. Switch to a lower demand exercise during periods of respiratory condition flare ups. Teach the client proper breathing techniques. There are breathing exercises such as “Pursed Lip Breathing” or “Diaphragmatic Breathing” that help with shortness of breath and the anxiety, fear, and embarrassment that may be present.

LEARN MORE

Fitness Learning Systems offers a Specialist Certificate Program for the 4 most prevalent Chronic Diseases. The Chronic Disease and Exercise Specialist Certificate Program contains 5 interactive online courses: Health Appraisal and Risk Assessment (3 hours); Healthy Heart for a Healthy Life (3 hours); Essential Exercise for Cancer Patients and Survivors (2 hours); Exercise, Diabetes, and Metabolic Syndrome (3 hours); and Respiratory Rescue-Understanding the Pulmonary Dysfunctional Client. (3 hours). Join the Medical Fitness profession and market yourself as a specialist by continuing your education with this 14 hour Specialist Certificate. All courses carry IACET CEUs.  Go to Course Chronic Disease and Exercise Specialist Certificate Program

About June Chewning
June has lead in many aspects of the fitness industry since 1978 including teaching physical education and aerobic classes, personal training, employee wellness, facility owner, college professor, and aquatic fitness professional training specialist. Currently she is president of Fitness Learning Systems and enjoys working with authors and organizations to format and develop accredited interactive continuing education eLearning courses.